Provider Demographics
NPI:1114110954
Name:FUNK, JOHN PERRY (LISW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PERRY
Last Name:FUNK
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N ARMIJO ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2582
Mailing Address - Country:US
Mailing Address - Phone:505-650-1111
Mailing Address - Fax:
Practice Address - Street 1:410 N ARMIJO ST
Practice Address - Street 2:APT. 2
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2582
Practice Address - Country:US
Practice Address - Phone:505-650-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-0581841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical